St. Francis Medical Center is again considering closing its century-old downtown Monroe campus and consolidating all acute care operations at its U.S. 165 North facility, which could leave an emergency room void in the heart of the city.

"We're exploring all of our options," said Kristin Wolkart, the hospital's chief executive. "St. Francis has had another challenging year so we're exploring all of our options that will allow us to continue our ministry in northeastern Louisiana."

Wolkart has briefed state lawmakers and Mayor Jamie Mayo. Those legislators and Mayo said Wolkart said the hospital suffered as much as a $25 million deficit last year.

"Nothing is final yet, but our (system) board meets Sept. 9," Wolkart said. St. Francis, the largest hospital in northeastern Louisiana, is part of the Franciscan Missionaries of Our Lady Health System.

Wolkart said the hospital continues to struggle with "some of the lowest Medicaid and uncompensated care reimbursements in the state. We've worked with the state, but it's been frustrating," she said.

Wolkart also point to other hospitals like Glenwood Regional Medical Center in West Monroe and Baton Rouge General also receive millions of dollars in another Medicaid stream by partnering with separate public entities and that St. Francis doesn't receive payments for treating uninsured patients.

"We're aware of (St. Francis') position and issues," said Jeff Reynolds, undersecretary of Louisiana's Department of Health.

Reynolds said the state's uninsured payments are focused on its partner safety net hospitals.

But Wolkart said the biggest expense is upkeep and maintenance on the ancient downtown campus. "It's a dinosaur," said Wolkart, who said the utilities alone average about $3.5 million per month.

The city of Monroe provided St. Francis with a $570,000 grant in 2015, which the hospital was able to leverage with the state to secure $1.4 million, in hopes to aid the hospital when it first considered closing its downtown campus and its Level 3 Neonatal Intensive Care Unit.

Mayo said there were no conditions in the grant, but he has asked Wolkart to demolish the old facility and donate the land to the city for development if the decision to close it moves forward.

"Those are my expectations after speaking with her," said Mayo, who believes the downtown site could be ideal for a new arena, one of his longtime priorities.

"St. Francis has been a mainstay of Monroe and northeastern Louisiana for more than 100 years and we hope it will be for another century, whether it's downtown or at the northern Monroe facility," the mayor said. "We understand that in the end the hospital must make tough decisions to remain viable."

Mayo and state Sen. Francis Thompson said their top priority if the hospital consolidates to St. Francis North is preserving an emergency center in downtown Monroe. St. Francis' downtown emergency center, unlike the rest of the campus, is a modern facility recently upgraded.

That could happen, Mayo, Thompson and Wolkart said, if St. Francis can come to an agreement with University Health Conway to continue to operate the emergency room.

"We don't want to leave a hole downtown," Wolkart said.

Thompson said University Health, which operates two of the state's safety net hospitals in Monroe and Shreveport, has agreed to explore a partnership to keep the emergency room open.

"We want all of our hospitals to thrive without a gap in any service," Thompson said.

Reynolds said the state will begin identifying how to fill the void if St. Francis decides to close the downtown campus.

"We're working with our partner hospital (Conway) about a long-term solution based on what St. Francis decides to do," he said.

Wolkart estimated it would cost up to $400 million to build a new hospital and more than $110 million to modernize the downtown facility. Both those options are cost prohibitive, she said.

Wolkart said it would take between $35 million and $50 million to renovate St. Francis North, which was built in the 1980s.

St. Francis North houses the Kitty DeGree Breast Care Center, an emergency room and other services but remains empty on floors two through six.

The hospital employs about 2,000 workers, including more than 1,500 who are full time.

Wolkart said it was preliminary to talk about a timeline or how a consolidation might impact employees.

St. Francis' decision could also affect P&S Surgical Hospital, which is connected to St. Francis with a crosswalk. P&S, a specialty hospital, is owned by physicians and St. Francis.

"We're committed to the partnership in whatever direction it takes," said Linda Holyfield, chief executive of P&S. "If St. Francis determines it must consolidate to St. Francis North, it may mean we relocate. Either way, we'll continue the work we do together.

Greg Hilburn covers state politics for the USA TODAY Network of Louisiana. Follow him on Twitter @GregHilburn1